Low Morbidity and Zero In-hospital Mortality in 1232 Gastric Bypasses in a Teaching Hospital

John Hwang, MD, Thomas Schnelldorfer, MD, David Brams, MD, Dmitry Nepomnayshy, MD. Lahey Hospital

BACKGROUND: Although gastric bypass has become increasingly safe, every bariatric program should strive for zero mortalities. We present a protocol for Roux-en-Y gastric bypass (GB) which has resulted in zero mortality in 1232 consecutive operations.

METHODS: Four different surgeons performed 1232 consecutive primary Roux-en-Y GB procedures. 79.4% of patients were female. Average initial BMI was 45.51. Average age was 43. Comorbidities included diabetes (25.4%), hypertension (45.5%), sleep apnea (37.5%), and reflux (47.6%). All patients undergo stringent screening and lifestyle modification classes and a weight loss requirement of 5-10% of their body weight. Patients who are unable to follow healthy lifestyle modifications are not offered surgery. After trying different techniques during our learning curve, all surgeons standardized their technique to a linear stapled, antecolic gastro-jejunostomy with a stapled enteric anastomoses.   All suturing is performed free-hand.  All fellows achieve proficiency in specific suturing skills in the simulation lab before performing surgery.  Performance of the case is transitioned from attending to trainee in a standardized fashion, starting with small bowel anastomosis, then gastric transection, second layer of enterotomy closure, first layer of enterotomy closure and finally mesenteric defect closure until the trainee performs the entire case.

RESULTS: There were no in-hospital deaths during the thirty day postoperative period. There was one patient who died due to an unrelated cause: a ruptured cerebral aneurysm. Overall readmissions occurred at 6.3% and reoperation occurred at 1.4%.

CONCLUSIONS: We report one of the highest single center case series for GB without an in-hospital mortality at a teaching hospital where trainees perform the procedure.  We feel that a combination of patient  selection and preparation, trainee preparation and surgical technique contribute to these results and should be considered by other teaching hospitals to minimize complication rates for gastric bypass surgery.